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Medical Societies

FACULTY OF RADIOLOGISTSAm the annual meeting held in Glasgow on June 28and 29 a discussion on the

Sarcomas of Soft Tissues

was opened by Prof. C. F. W. ILLINGWORTH, whoreported a series of cases treated at the Western Infir-mary, Glasgow, over a considerable period. He included

reticulosarcoma, lymphosarcoma, fibrosarcoma, myxo-sarcoma, myosarcoma, and other rare types. Exceptfor the sarcomas of lymph-nodes, which are radio-sensitive but dangerous because of the rapidity withwhich they grow and spread, the sarcomas are resistantto radiation and very difficult to treat by surgery. Thefew patients who survived for long periods had beentreated by surgery and radiotherapy, but it was hard tobe certain that the postoperative radiation made muchdifference.

Prof. R. A. WiLLis said that the sarcomas of softparts are among the most difficult of the tumours aboutwhich pathologists are asked to give an opinion. Someof them are so undifferentiated that it is impossibleeven to decide whether they are sarcomas or carcinomas.This is understandable if the development of the con-nective tissues from the primitive mesenchyme is remem-bered. Many of the fully differentiated cells are capableof tumour formation, and these tumours are easilydiagnosed and described ; but there are also mesenchymalcells necessary for normal growth and repair which retainthe power of differentiating into several different kindsof cell. It is therefore not surprising that tumours ofconnective tissue are found containing areas whichappear on section to be entirely different and are

described by a long string of names. Professor Willisthought that the name " mesenchymoma " should be usedfor these tumours. He illustrated his points by slidesof sections in which a wrong diagnosis had been made,the true nature of the condition being apparent onlypost mortem.

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Dr. WALDRON SMITHERS believed that some improve-ment in the results of radiotherapy of malignant tumoursmight be obtained by more careful study of time andintensity. Dr. C. J. L. THURGAR described an investi-gation undertaken at Newcastle to discover whetherheat derived from short-wave diathermy is a usefuladjunct to radiotherapy. Some benefit, he thought, hadbeen obtained.

Nuclear Physics and Medical ResearchProf. P. I. DEE sketched the technical advances of the

last ten years-the cyclotron, betatron, and linearaccelerators which give X rays at powers as high as100 million volts, and neutron beams, and may shortlyallow tests to be made with an electron beam for therapy.The transmutation of elements is now, he said, a common-place reaction, and radioactive isotopes of any elementcan be obtained. The uranium pile can produce verylarge quantities of such therapeutic agents as radioactivephosphorus and cobalt, so research is no longer limitedby the small amounts previously obtainable from earlyexperiments with alpha particles and the beam from thecyclotron.

Prof. A. S. MACFARLANE summarised the work donein the U.S.A. and Sweden using radioactive isotopes astracers. Radioactive sodium chloride has been used todetermine the rate of diffusion by the blood-stream andto measure the lymph volume of particular organs.Iron serves to determine unit volume of the blood andthus to investigate- surgical shock. It has two isotopeswith different properties which can be picked out byspecial measuring instruments, and this fact has beenused to determine the relative survival in the blood-stream of stored and fresh blood. Also a mechanismhas been demonstrated by which iron from hsemolysedblood is taken up by the new cells in preference to thatsupplied from without, even if given in large quantities.Hevesy, whose work in this field is already famous, hasshown, working with the nucleated red cells of avianblood, that their survival-time is exactly 28 days, andhe has also used radioactive phosphorus to investigategrowth both of normal and of tumour cells. This kind of

biochemistry may be described as dynamic, and showsto what an astonishing extent the chemical substances inall tissues are replaced during the life-span. In thespace of ten years every molecule present in the livingbody of man will have been replaced by a new moleculesynthesised within the framework of the living cells.

Dr. J. S. MITCHELL also spoke of the importance oftracer research, particularly in the investigation of newgrowth. In therapy the use of radioactive phosphorusto treat leukaemia is well established, but the results sofar are very similar to those of ordinary irradiation ofthe spleen. For other conditions isotopes of calcium,strontium, and iodine have been tried, but improvementhas been obtained only occasionally.

TUBERCULOSIS ASSOCIATION

AT a meeting in London on May 17, with Dr. NORMANTATTERSALL, the president, in the chair, a paper on

Primary Pleurisy with Effusionwas read by Dr. BRIAN THOMPSON, who reported on190 patients seen, between 1937 and 1944, in the urbanindustrial area served by the Ealing Chest Clinic. Atthe time of onset in each case evidence of parenchymaldisease was either absent or limited to primary intra-thoracic lesions. There was a high incidence of precedingor concurrent intrathoracic lesions typical of primarytuberculosis, sometimes confirmed by the later develop-ment of calcification. Cavity formation occurred in 5patients with these lesions, which were not always onthe same side as the effusion ; but the incidence of bothprimary lesions and effusions was higher on the right.

Pleurisy with effusion was found predominantly in theyears of late adolescence and young adult life. There wasan excess of males over females in the 15-19 age-group.The follow-up for the maximum periods of one to eight

years revealed subsequent tuberculosis in 12 % withinthe first year, in another 8 % in the second year, and ina total of 25 % ’within five years. In 15 % of thesepatients the first evidence of disease was extrapulnonary.The death-rate for the 190 cases over the five-year periodwas 3’5 %. Age was not related to the incidence ofsubsequent tuberculosis or its prognosis.The condition was attributed by Dr. Thompson to

infection of the pleural cavity from a subpleural focusor caseous glands, rather than to postprimary dissemina-tion through the blood-stream. The former was sup-ported by the absence of miliary lesions and by thetendency of both effusions and foci (when visible) to

appear on the right side. A second effusion on theopposite side might be explained by lymph-node exten-sion of infection across the mediastinum. Relativelyfew of the gross primary lesions underwent calcification.

There was a low incidence of known contact with tuber-culosis, and the general picture was one of young personsescaping first infection in childhood, only to meet itsuddenly, perhaps in a single massive dose, in the unaccus-tomed industrial or barrack life.

Pleurisy with effusion, he concluded, ’had probablybecome commoner under war-time conditions in England,reaching an incidence of one-tenth that of intrathoracictuberculosis. In the absence of reinfectious diseaseor a non-tuberculous condition, the pleurisy was usuallya manifestation of recent primary tuberculous infection.The condition occurred typically in young adults, whoreacted differently to children ; and the effusion waslikely to follow first infection within six months. Phthisis,when it occurred, did so usually within the next year andalmost always within two years. Though there wasno evidence of any factor which influenced the march ofevents, it would be wise to continue the generally acceptedlines of treatment, with careful radiological supervisionfor the five subsequent years.

Dr. W. R. RICHARDS said that, of pleural effusions inchildren at High Wood Hospital, 24 % were at ages6-9, 34 % at 10-15. In younger children they wereassociated with serious complications. In adolescents,cases of effusion sometimes slipped quickly into phthisis.

Replying to further speakers Dr. THOMPSON saidthat the two cases with calcification observed byhim had been quite young, and he did not agree that ittook time for a primary infection to die out. He thoughtthat patients in sanatoria were not liable to super-

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infection there. He defended the use of the terms" reinfection " and " phthisis."

Morbidity of TuberculosisMr. W. T: RUSSELL, .sc., recalled the uninterrupted

decline in the standardised death-rates between 1851and 1916. Mortality increased during the first worldwar, but with the exception of a few oscillations in

influenzal years the curve was chiefly downwards until1939. Though it was possible that tuberculosis mighthave its waves of increment and decrement, the declinein recent times might have three causes : a more tuber-culised population owing to increased urbanisation;increase of resistance through environmental factors;and better diagnosis and treatment. In the age-group15-25 the death-rate of females did not decline between1913 and 1933. Stocks had suggested that the failure ofthis age-group mortality to decline between 1926 -and’

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1935 might be due to these persons being childrenduring world war I and having their resistance lowered.But mortality was not the right index of measurement.Morbidity figures would probably better relate events to theparticular environment in which they had their inception -.Formal notifications numbered nearly 50,000 in 1931,

35,000 in 1939, and 43,000 in 1944, the war-timeincidence affecting males much more than females.In the years 1940-44, 163,000 notifications were

expected, but 202,500 actually occurred. Possibly theexplanation lay partly in diagnosis on entry to theForces and in mass radiography. During the three years,1942-44, the increase of incidence over the 1936-38rate was 12 % in Wales but 25 % in London, whichfirst showed the changed direction of the curve in 1939-41.In Glasgow there was an increase of 48 % for males and65 % for females (78 % and 121 % in age-group 0-15).

Dr. NoRMAN ENGLAND said that up to now the onlymoderately accurate data in our possession had concernedfatalities ; we knew next to nothing about morbidityand nothing even about the proportion of those primarilyinfected in each age-group who eventually developeddisease. We must be able to measure the success orfailure of our own attacks on the disease, and thestatistical method was the only one which would guardus against inaccuracy. The requirements were (1)careful truthful records ; (2) sure " national " statistics ;(3) a campaign which, while based on proven experience,had a place for new methods ; (4) the setting up of acentral Bureau of Tuberculosis Statistics to organiseand carry out inquiries.The meeting resolved " that the council of the Tuber-

culosis Association should consider approaching theJoint Tuberculosis Council with a request that a Bureauof Statistics for Tuberculosis problems should be set up."

Reviews of Books

Rare Diseases and Some Debatable SubjectsF. PARKES WEBER, M.D., F.R.C.P. London : StaplesPress. Pp. 174. 158.

ACCOUNTS are here collected in one small volume ofa number of the conditions which Dr. Parkes Weber hasso often interpreted at medical meetings. His title isapt, for no-one is more knowledgable of rare diseases,or more able and willing to debate them with kindnessand patience. " Disease," he writes on the first page,is often a " courtesy title " for a syndrome of unknowncausation. Thus some fibrocystic diseases of bone aresyndromes, whereas hyperparathyroidism is a disease,the cause of which-a parathyroid adenoma-is known.Rare diseases, few of which any doctor is likely to seeunless he attends clinical societies, are not exceptions tonature’s laws; they may be valuable guides which"

prove "-that is, test-the rules and theories of com-moner diseases, shedding light upon genetic or otherantecedents.

Over thirty conditions or groups are included, omittingthe blood diseases and some others. The Sturge-Kalischer-Weber disease (adopting Dr. K. Blum’s nomenclature,modestly relegated by the author to a footnote) is onethat, like several others, could hardly fail, if once seen,to be recognised ; unfortunately the radiogram is notvery clear. Various uncommon affections of the skin andsubcutaneous tissues, including blushing and flushing,

are described ; and rheumatic nodules, thrombo-angiitisobliterans, Paget’s bone disease, and some familialrelations are well discussed. In a family subject to" renal " glycosuria, intercurrent illnesses had beenascribed to diabetes mellitus and one member had beentreated with insulin. There is a chapter upon the agnosiaof hemiplegia, especially that of cerebral blindness, thepatient denying both the blindness and the paralysis;one man claimed that he could see everything, thoughhe thought in broad daylight that it was night. Thedistinction from hysterical blindness is discussed.Any doctor of experience who owns this valuable little

book will say to himself, probably more than once, " Ihave seen this or that complaint but did not recognise it."

Acquisitions medicales recentes dans les pays alliesA. ABAZA, ancien interne des hopitaux de Paris. Paris :G. Doin. Pp. 706. Frs. 1000.

Dr. Abaza, who is deputy director of the epidemiccontrol and medical intelligence branch of the healthdivision in London of UNRRA, has summarised for hisfellow-countrymen the advances in therapeutics in thiscountry and in the United States sirice the fall of Francein 1940. Penicillin, the sulphonamides, thiouracil, thenewer insulins, the synthetic oestrogens, and a host ofother subjects are reviewed, and in every case a very fullbibliography is provided. This is international coöpera-tion at its best, and we congratulate Dr. Abaza on hisskill in presenting such a vast subject so cogently.Many Englishmen and Americans will also benefit fromstudying the book. Perhaps Dr. Abaza will considerproviding English readers with a survey of the advancesin medicine-such as the treatment of lupus with massivedoses of vitamin D-made in France during the yearsof the occupation.Pathology of Tropical Diseases

An Atlas. J. E. ASH, colonel, M.C., A.U.S., director,Army Institute of Pathology, Army Medical Museum;SOPHIE SPITZ, M.C., G.S., A..U.S., pathologist to theinstitute. London : W. B. Saunders. Pp. 350. 40s.

Tins well-balanced atlas sets forth the pathology oftropical and allied conditions, including the virus diseases,bartonellosis, the rickettsial diseases, the tropical trepo-nematoses, and the spirochaetal infections, and the com-moner tropical bacterial diseases. The protozoal, ciliate,and other types of colonic disease are described in thesection dealing with bacillary dysentery, and furtherchapters describe the pathology of the more importantprotozoal infections, malaria, leishmaniasis, and trypano-somiasis. There are good sections on the various fungaldiseases, and the main nematode, trematode, and cestodeinfestations. A short chapter on the effects of heatis followed by sections dealing with the pathologyof various deficiency diseases. The detailed pathology ofeach condition is clearly described, and the book is wellillustrated by photographs, maps, and diagrams. A briefaccount of the epidemiology, diagnosis, and clinicalfeatures of each condition ensures that the pathology isintegrated into the whole disease picture.Pre-School Centres in Australia

(The Lady Gowrie Child Centres.) J. H. L. CUMPSTON,M.D., Commonwealth Director-General of Health ;CHRISTINE M. HEINIG, M.B., Federal Education Officer,Australian -Association for Pre-School Child Develop-ment. Canberra : Commonwealth Dept. of Health.Pp. 229.

LIKE the illustrated sales catalogues studied enviouslyin childhood, this is for us a record of the unattainable,for it describes a spacious and pleasant expansion -ofnursery schools. The first official nursery schools inAustralia were built in war-time, but the book alsodescribes a programme for building and equipping sixpre-school centres in six capital cities. Staff and equip-ment in this country would never be forthcoming torun three separate nurseries for 2-year-old, 3-year-old,and 4-year-old children, but not all would advocate it.Perhaps less detail might have been given about spaceand equipment, which is bound to be affected by localconditions, and more about staffing and personnel, andthe more general problems raised by the care of thechildren themselves. Nurseries, even as beautiful asthese, do not survive in their bricks and mortar only.